HDM
What type of play is typical of toddlers? A. Solitary B. Parallel C. Associative D. Competitive/Cooperative
B. Parallel Rationale: Toddlers observe other children and then engage in activities nearby
Based on knowledge of the developmental tasks of Erikson's Industry versus Inferiority, the nurse emphasizes proper technique for use of an inhaler with a 10-year-old boy so he will: A. Increase his self-esteem with mastery of a new skill. B. Accept changes in his appearance and physical endurance. C. Experience success in role transitions and increased responsibilities. D. Appreciate his body appearance and function.
A. Increase his self-esteem with mastery of a new skill.
A nurse provides medication instructions to a first-time mother. Which statement made by the mother indicates a need for further instructions? A. "I should mix the medication in the baby food and give it when I feed the child". B. "I should administer the oral medication sitting in an upright position and with the head elevated". C. "I will give my child a toy after giving the medication". D. "I will offer my child a juice drink after swallowing the medication".
A. "I should mix the medication in the baby food and give it when I feed the child". Rationale: The nurse would teach the mother to avoid putting medications in foods because it may cause an unpleasant taste to the food, and the child may refuse to accept the same food in the future. Additionally, the child may not consume the entire serving and would not receive require medication dosage. Option B: Administering the medication in an upright position and head elevation will prevent the risk of aspiration. Option C: Offering a toy will provide comfort measures to the child. Option D: The mother should offer drink such as juice or a soft drink to lessen the aftertaste of the medication.
Cherry, the mother of an 11-month-old girl, Elizabeth, is in the clinic for her daughter's immunizations. She expresses concern to the nurse that Elizabeth cannot yet walk. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is: A. 12 months. B. 15 months. C. 10 months. D. 14 months.
A. 12 months.
The parent of a 3-month-old infant asks the nurse, "At what age do infants usually begin drinking from a cup?" The nurse would reply: A. 6 months. B. 9 months. C. 1 year. D. 2 years.
A. 6 months.
An infant should be immediately evaluated by a physician if which of the following signs or symptoms are present? A. Acting fussier than normal B. Temperature of 37 degrees (98.6 F) C. Refuses a pacifier D. Use of abdominal muscles to breathe
A. Acting fussier than normal
A nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to: A. Allow the newborn infant to signal a need B. Anticipate all of the needs of the newborn infant C. Avoid the newborn infant during the first 10 minutes of crying D. Attend to the newborn infant immediately when crying
A. Allow the newborn infant to signal a need Rationale: According to Erikson, the caregiver should not try to anticipate the newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn's signal would inhibit the development of trust and lead to mistrust of others.
The nurse is assessing a four-month-old infant. The nurse would anticipate finding that the infant would be able to A. Hold a rattle B. Bang two blocks C. Drink from a cup D. Wave "bye-bye"
A. Hold a rattle
A child with croup is admitted to the hospital, and the health care provider prescribes a cool-mist tent. The child is fearful and crying. Which nursing intervention is appropriate? A. Ask the mother to bring the child's favorite toy from home. B. Ask the health care provider for a prescription for a mild sedative. C. Obtain a toy from the playroom for the child to bring into the tent. D. Ask the health care provider to change the prescription from the mist tent to oxygen via nasal cannula.
A. Ask the mother to bring the child's favorite toy from home. Rationale: Familiar objects provide a sense of security for the child in a strange hospital environment. The child should be allowed to have a favorite toy or security blanket while in the mist tent (per agency policies). Options 2 and 4 are inappropriate. Option 3 will not provide the child with a favorite toy.
The nurse employed in a well-baby clinic is providing nutrition instructions to a mother of a 9-month-old infant. Which instruction is appropriate? A. Begin to initiate self-feeding. B. Introduce strained fruits 1 at a time. C. Introduce strained vegetables 1 at a time. D. Begin to offer rice cereal mixed with breast milk or formula.
A. Begin to initiate self-feeding. Rationale: Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats, introduced one at a time, can begin at 6 months of age. Self-feeding can be initiated at approximately 9 months of age.
When developing an appropriate outcome for a 15-year-old girl, the nurse considers that a primary developmental task of adolescence is to: A. Form a sense of identity. B. Create intimate relationships. C. Separate from parents and live independently. D. Achieve positive self-esteem through experimentation.
A. Form a sense of identity.
A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first? A. Heart rate, respiratory rate, and blood pressure B. Recent exposure to communicable diseases C. Number of immunizations received D. Height and weight
A. Heart rate, respiratory rate, and blood pressure The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather the other data later.
The parents of a child, age 6, who will begin school in the fall ask the nurse for anticipatory guidance. The nurse should explain that a child of this age: A. Is highly sensitive to criticism B. Loves to tattle C. Still depends on the parents D. Rebels against scheduled activities
A. Is highly sensitive to criticism Rationale: In a 6-year-old child, a precarious sense of self causes overreaction to criticism and a sense of inferiority. By age 6, most children no longer depend on the parents for daily tasks and love the routine of a schedule. Tattling is more common at age 4 to 5, by age 6, the child wants to make friends and be a friend
The infant of a substance-abusing mother is at risk for developing a sense of which of the following? A. Mistrust B. Shame C. Guilt D. Inferiority
A. Mistrust Rationale: According to Erikson, infants need to have their needs met consistently and effectively to develop a sense of trust. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment. Toddlers develop a sense of shame when their autonomy needs are not met consistently. Preschoolers develop a sense of guilt when their sense of initiative is thwarted. School agers develop a sense of inferiority when they do not develop a sense of industry.
While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should: A. Notify the doctor B. Look for other signs of abuse C. Recognize this as a normal finding D. Ask about family history
A. Notify the doctor Rationale: Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the doctor promptly of this finding. An open fontanel does not indicate abuse
Nurse Walter should expect a 3-year-old child to be able to perform which action? A. Ride a tricycle B. Tie the shoelaces C. Roller-skates D. Jump rope
A. Ride a tricycle At age 3, gross motor development and refinement in eye-hand coordination enable a child to ride a tricycle. The fine motor skills required to tie shoelaces and the gross motor skills requires for roller-skating and jumping rope develop around age 5.
When developing a plan care for a hospitalized child, nurse Mica knows that children in which age group are most likely to view illness as a punishment for misdeeds? A. Infancy B. Preschool age C. School age D. Adolescence
B. Preschool age
To maintain a child's developmental skills while hospitalized, the nurse should encourage what types of activities to a 1-year-old child who was born 2 months earlier than the estimated date of delivery? A. Sitting independently B. Walking independently C. Building a tower of 3 blocks D. Indicating wants by pointing or grunting
A. Sitting independently Rationale: For preterm infants, the nurse needs to calculate the developmental age by deducting the time of prematurity from the age of the child until he or she reaches the age of 2 years. In this case, 2 months need to be subtracted from 1 year, equaling 10 months of age. A 10-month-old can sit independently. By 15 months of age, a child should walk independently and indicate wants by pointing and grunting. By 18 months of age, a child should be able to build a tower of 3 blocks.
An important physical development issue among adolescent boys is what? A. The development of facial hair B. The growth of breasts C. The development of peer relationships D. The ability to state one's needs
A. The development of facial hair Rationale: The development of facial hair is an important physical development issue among adolescent boys. The growth of breasts is a female issue and the development of peer relationships and the ability to state one's needs are psychosocial issues.
In terms of cognitive development the 5-year-old child would be expected to: A. Use magical thinking. B. Think abstractly. C. Understand conservation of matter. D. Be able to comprehend another person's perspective.
A. Use magical thinking. Rationale: Magical thinking is believing that thoughts can cause events. Abstract thought does not develop until school-age years. The concept of conservation is the cognitive task of school-age children ages 5 to 7 years. Five-year-olds cannot understand another's perspective.
A clinic nurse assesses the communication patterns of a 5-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement expected if the infant: A) Uses simple words such as "mama" B) Uses monosyllabic babbling C) Links syllables together D) Coos when comforted
B) Uses monosyllabic babbling Rationale: Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as "mama" occurs between 9 and 12 months. Linking syllables together when communicating occurs between 6 and 9 months. Cooing begins at birth and continues until 2 months.
Cristina, a mother of a 4-year-old child tells the nurse that her child is a very poor eater. What's the nurse's best recommendation for helping the mother increase her child's nutritional intake? A. Allow the child to eat at a small table and chair by herself B. Allow the child to feed herself C. Only serve the child's favorite foods D. Use specially designed dishes for children - for example, a plate with the child's favorite cartoon character
B. Allow the child to feed herself Rationale: The best recommendation is to allow the child to feed herself because the child's stage of development is the preschool period of initiative. Special dishes would enhance the primary recommendation. The child should be offered new foods and choices, not just served her favorite foods. Using a small table and chair would also enhance the primary recommendation.
During a well-child visit, a mother states she is frustrated with her 2-year-old son because whenever she asks him whether he wants something to eat he says, "no," but then starts to cry when she does not give him the food. Which statement by the nurse indicates an understanding of psychosocial concepts related to the growth and development of the toddler? A. "Your toddler is only 2 years old and you should not be giving him choices. He is too young." B. "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." C. "Your toddler is still in the stage of trust versus mistrust, and you need to spend more time with him so that he feels more secure." D. "Your toddler is experiencing magical thinking, and with this stage if he says "no," he believes you will know he means the opposite."
B. "Your toddler is asserting his independence as he is progressing through the stage of autonomy versus shame and doubt." Rationale: According to Erikson, toddlers are acquiring a sense of autonomy while overcoming a sense of shame and doubt. They are attempting to relinquish their dependence and asserting independence, which will be present as negativism in their quest for independence. The word, no, is a very strong part of their vocabulary. Therefore, options 1, 3, and 4 are inaccurate.
The nurse is preparing to administer an intramuscular injection to a 10-year-old child in the vastus lateralis muscle. Which value indicates the maximum volume of medication that can be safely administered into this muscle? A. 0.5 mL B. 1.5 mL C. 2.5 mL D. 3 mL
B. 1.5 mL Rationale: In a child ages 6 to 14 years, the maximum volume of intramuscular medication that can be safely administered into the vastus lateralis muscle is 2 mL. The maximum volume of intramuscular medication that can be safely administered into the vastus lateralis is 0.5 to 1 mL
A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her birth weight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her weight to be at least _____ pounds. A. 12 B. 16 C. 20 D. 24
B. 16 Rationale: Birth weight is usually doubled by 6 months of age.
Which statement accurately describes physical development during the school-age years? A. The child's weight almost triples. B. A child grows an average of 2 inches per year. C. Few physical differences are apparent among children at the end of middle childhood. D. Fat gradually increases, which contributes to the child's heavier appearance.
B. A child grows an average of 2 inches per yea
When administering a liquid medication to an uncooperative toddler, the nurse should implement which strategy? A. Restrain the child in a high chair. B. Allow the parents to remain in the room. C. Restrain the child in a papoose-type device. D. Remove the child to another room away from the parents.
B. Allow the parents to remain in the room. Rationale: Allowing the parents to remain in the room will promote positive parent-child relationships as well as decrease the irrational fears that are so common in this age-group. Option 4 is incorrect, because separation anxiety will only increase the child's fears. Options 1 and 3 are unnecessarily restrictive and will not increase cooperation.
A nurse is teaching a preschool-aged child. Which teaching method is most appropriate for the nurse to use when teaching a child in this age group? A. Demonstrations B. Coloring books C. Small groups D. Videos
B. Coloring books
The nurse is assessing the vital signs of a 3-year-old child and notes that the respiratory rate is 28 breaths per minute. Based on this finding, which nursing action is appropriate? A. Administer oxygen. B. Document the findings. C. Notify the health care provider. D. Reassess the respiratory rate in 15 minutes.
B. Document the findings. Rationale: The normal respiratory rate for a 3-year-old child is approximately 20 to 30 breaths per minute. Because the respiratory rate is normal, options 1, 3, and 4 are unnecessary actions. The nurse would document the findings.
The nurse is performing an assessment on a preschool child. What should the nurse do in order to facilitate the cooperation of the child? A. Have the parents leave the room. B. Have the child pretend to be the nurse. C. Offer information and answer questions. D. Explain in detail each part of the examination before doing it
B. Have the child pretend to be the nurse. Rationale: According to Erik Erikson, preschoolers are in the initiative stage of development. They pretend, explore, and try out new roles. They primarily look for the fun in activities, not the reasoning behind the activity. Parental involvement is usually important for all ages of children especially during the younger years. The child would not be interested in or understand information or details.
According to Erikson, the psychosocial task of adolescence is developing: A. Intimacy. B. Identity. C. Initiative. D. Independence.
B. Identity.
The nurse is assigned to care for a hospitalized toddler. Which measure should the nurse plan to implement as the highest priority of care? A. Providing a consistent caregiver B. Protecting the toddler from injury C. Adapting the toddler to the hospital routine D. Allowing the toddler to participate in play and diversional activities
B. Protecting the toddler from injury Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Whereas consistency, adaptation, and diversion are important, protection from injury is the highest priority.
If parents keep a toddler dependent in areas where he is capable of using skills, the toddler will develop a sense of which of the following? A. Mistrust B. Shame C. Guilt D. Inferiority
B. Shame Rationale: According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Infants develop mistrust when their needs are not consistently gratified. Preschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met.
The nurse is assessing a six-month-old child. Which developmental skills are normal and should be expected? A. Speaks in short sentences. B. Sits alone. C. Can feed self with a spoon. D. Pulling up to a standing position.
B. Sits alone.
A 9-year-old child is hospitalized for 2 months after a car accident. Which intervention should the nurse plan to use to best promote psychosocial development? A. Providing a portable media player (MP3) B. Tutoring to keep the child up with schoolwork C. Providing a phone for calling family and friends D. Placing computer games, a television, and videos at the bedside
B. Tutoring to keep the child up with schoolwork Rationale: The developmental task of the school-age child is industry versus inferiority. The child achieves success by mastering skills and knowledge. Maintaining schoolwork provides for accomplishment and prevents feelings of inferiority that may be caused by lagging behind the rest of the class. The other options provide diversion and are of lesser importance for a child of this age.
A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min. Abdominal breathing in this patient should be viewed as a: A. sign of impending respiratory failure. B. normal finding for a toddler. C. sign of decreased perfusion to the respiratory center. D. compensatory mechanism to increase the volume of air inhaled and respiratory rate.
B. normal finding for a toddler.
A 2-year-old girl who is having difficulty breathing and a barky cough has had a fever and runny nose for the past 3 days. She is alert and sitting on her mother s lap. Assessment reveals that she has warm, flushed skin, is using her abdominal muscles to breathe, and has increased work of breathing. She has a blood pressure of 88/66 mm Hg, a pulse of 128 beats/min, and respirations of 48 breaths/min. You should immediately determine whether the patient has: A. delayed capillary refill time. B. stridor. C. the ability to tolerate oral feedings. D. weak pulses
B. stridor.
The nurse in a well-baby clinic is providing safety instructions to the mother of a 1-month-old infant. Which safety instructions are most appropriate at this age? Select all that apply. A. Lock up all poisons. B. Cover electrical outlets. C. Never shake the infant's head. D. Place the infant on the back to sleep. E. Remove hazardous objects from low places.
C and D Rationale: The age-appropriate instructions that are most important are to instruct the mother not to shake or vigorously jiggle the baby's head and to place the infant on his back to sleep. Options 1, 2, and 5 are important instructions to provide to the mother as the child reaches the age of 6 months and begins to explore the environment.
Which of the following terms accurately describes toddlers? A. Creative B. Invincible C. Dependent D. Egocentric
D. Egocentric Rationale: -Creativity is a trait of middle adults -Invincibility is a trait of adolescents (their feeling of invincibility leads to risky behaviors) -Dependence is a trait of infants (toddlers want to be independent) -Toddlers are unable to see things from another's perspective. They can only see things from their point of view (egocentric)
A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction? A. "I need to use the back burners for cooking." B. "I need to remain in the kitchen when I prepare meals." C. "I need to be sure to place my cup of coffee on the counter." D. "I need to turn pot handles inward and to the middle of the stove."
C. "I need to be sure to place my cup of coffee on the counter." Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water or hot objects placed on counters and open fires or burners on stoves above their eye level. The mother's statement in option 3 does not indicate an adequate understanding of the principles of safety. Hot liquids should never be left unattended, and the toddler should always be supervised. Parents should be encouraged to use the back burners on the stove, remain in the kitchen when preparing a meal, and turn pot handles inward and toward the middle of the stove.
The community health nurse is providing instructions to a group of mothers regarding the safe use of car seats for toddlers. The nurse determines that the mother of a toddler understands the instructions if the mother makes which statement? A. "The car seat should never be placed in a face-forward position." B. "The car seat can be placed in a face-forward position at any time." C. "The car seat is suitable for the toddler until the toddler reaches the weight of 40 pounds." D. "The car seat can be placed in a face-forward position when the height of the toddler is 27 inches."
C. "The car seat is suitable for the toddler until the toddler reaches the weight of 40 pounds." Rationale: The transition point for switching to the forward-facing position is defined by the manufacturer of the safety seat but is generally at a body weight of 9 kg (20 pounds). The car safety seat should be used until the child weighs at least 40 pounds, regardless of age. Options 1, 2, and 4 are incorrect.
During a routine well-child checkup for a 2-year-old child, the nurse plans to teach the mother proper nutrition and weight gain expectations for her child. The nurse reviews the chart and finds that the toddler's birth weight was 7 pounds 15 ounces. What should the nurse expect the child's weight to be at this time? A. 15 pounds 14 ounces B. 23 pounds 13 ounces C. 31 pounds 12 ounces D. 39 pounds 11 ounces
C. 31 pounds 12 ounces Rationale: By the age of 30 months, the toddler should have quadrupled his or her birth weight. The child doubles the birth weight by age 5 to 6 months and triples the birth weight by 1 year of age. Option 3 is quadruple the birth weight.
The infant is sitting alone using its arms for support. At what age is this child at this stage of motor development? A. 3 months B. 4 months C. 7 months D. 12 months
C. 7 months
A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? A. Encourage independent learning. B. Use discussion throughout the teaching session. C. Apply a bandage to a doll's ear. D. Develop a problem-solving scenario.
C. Apply a bandage to a doll's ear. Rationale: Use play to teach a procedure or activity (e.g., handling examination equipment, applying a bandage to a doll) to toddlers. Encouraging independent learning is for the middle-aged adult. Use of discussion is for older children, adolescents, and adults, not for toddlers. Use problem solving to help adolescents make choices. Problem solving is too advanced for a toddler.
Which of the following is an appropriate toy for an 18-month-old? A. Multiple-piece puzzle B. Miniature cars C. Finger paints D. Comic book
C. Finger paints Rationale: Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Thus, finger paints would be an appropriate toy choice. Multiple-piece toys, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Miniature cars also have a high potential for aspiration. Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart.
A 10-year-old fifth-grader enjoys having his artwork displayed on the family refrigerator. This behavior is indicative of which developmental stage as described by Erikson? A. Initiative versus guilt B. Intimacy versus isolation C. Industry versus inferiority D. Identity versus role confusion
C. Industry versus inferiority
The nurse is caring for a child hospitalized with laryngotracheal bronchitis (LTB). Which sign/symptom, if noted in the child, indicates respiratory distress? A. Agitation B. Dehydration C. Nasal flaring D. Brassy respirations
C. Nasal flaring Rationale: Signs of respiratory distress include nasal flaring; the use of accessory muscles; substernal, intercostal, and suprasternal retractions; and restlessness. Option 1 may be an indication of increasing respiratory distress, but it can also indicate several other clinical problems. Option 2 is not a sign of respiratory distress. Option 4 describes an early and classic manifestation of LTB.
Which of the following is the most appropriate activity for a 5-year-old child? A. Squeeze toy. B. Board games. C. Play-Doh. D. Computer games.
C. Play-Doh. Rationale: In the preschooler, play is simple and imaginative and includes activities such as puppets, play-doh, and coloring book. Squeeze toys are appropriate for infants Board games are appropriate for the school-age child. Computer games are appropriate for an adolescent.
When developing a plan care for a hospitalized child, nurse Mica knows that children in which age group are most likely to view illness as a punishment for misdeeds? A. School age B. Infancy C. Preschool age D. Adolescence
C. Preschool age Rationale: Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age group, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.
Magical Thinking is an attribute of which age group? A. Infants (birth - 1 year) B. Toddlers (1 -3 years) C. Preschoolers (3 - 6 years) D. School-Age Children (6 - 12 years)
C. Preschoolers (3 - 6 years)
During a well-baby visit, Liza asks the nurse when she should start giving her infant solid foods. The nurse should instruct her to introduce which solid food first? A. Applesauce B. Egg whites C. Rice cereal D. Yogurt
C. Rice cereal Rice cereal is the first solid food an infant should receive because it is easy to digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt, and finally, meat. Egg whites should not be given until age 9 months because they may trigger a food allergy.
A mother of a three (3)-year-old tells a clinic nurse that the child is constantly rebelling and having temper tantrums. The nurse most appropriately tells the mother to: A. Punish the child every time the child says "no", to change the behavior B. Allow the behavior because this is normal at this age period C. Set limits on the child's behavior D. Ignore the child when this behavior occurs
C. Set limits on the child's behavior Rationale: Being consistent and setting limits on the child's behavior are the necessary elements. A and D: Saying things like "no" or "mine" and having temper tantrums are common during this period of development. B: According to Erikson, the child focuses on independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes.
The nurse employed in a well-baby clinic is collecting data regarding the motor development of an 18-month-old child. What should the nurse expect as the highest level of development in this child? A. The child snaps large snaps. B. The child builds a tower of 2 blocks. C. The child builds a tower of 3 or 4 blocks. D. The child puts on simple clothes independently.
C. The child builds a tower of 3 or 4 blocks.
he nurse is assessing a 9-month-old boy for a well-baby check up. Which of the following observations would be of most concern? A. The baby cannot say "mama" when he wants his mother. B. The mother has not given him finger foods. C. The child does not sit unsupported. D. The baby cries whenever the mother goes out.
C. The child does not sit unsupported. Over 90% percent of babies can sit unsupported by nine months. Most babies cannot say "mama" in the sense that it refers to their mother at this time.
An infant who has been in foster care since birth requires a blood transfusion. Who is authorized to give written, informed consent for the procedure? A. The nurse-manager B. The registered nurse caring for the infant C. The foster mother D. The social worker who placed the infant in the foster home
C. The foster mother Rationale: When children are minors and aren't emancipated, their parents or designated legal guardians are responsible for providing consent for medical procedures. Therefore, the foster mother is authorized to give consent for the blood transfusion. The social workers, the nurse, and the nurse-manager have no legal rights to give consent in this scenario.
The nurse is giving instructions to an 8-year-old child regarding measures to take to identify the early signs of an asthma episode. What instruction would be important for the nurse to give the child? A. Perform chest percussion and postural drainage. B. Open the airway passages by using a hand-held nebulizer. C. Use a peak flowmeter to measure for a drop in the expiratory flow rate. D. Deliver a dose of a bronchodilator by a metered-dose inhaler to see if it helps.
C. Use a peak flowmeter to measure for a drop in the expiratory flow rate. Rationale: An asthmatic child older than the age of 4 should be able to measure the expiratory flow. A drop in expiratory flow is the most reliable early sign of an asthma episode. Chest percussion and postural drainage are normally used to clear air passages for children with cystic fibrosis, not asthma. Medications would be administered by a metered-dose inhaler or by a hand-held nebulizer if an asthma attack actually occurs.
Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night? A. "Allow him to fall asleep in your room, then move him to his own bed." B. "Tell him that you will lock him in his room if he gets out of bed one more time." C. "Encourage active play at bedtime to tire him out so he will fall asleep faster." D. "Read him a story and allow him to play quietly in his bed until he falls asleep."
D. "Read him a story and allow him to play quietly in his bed until he falls asleep." Rationale: Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child's going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.
By the end of which of the following would the nurse most commonly expect a child's birth weight to triple? A. 4 months B. 7 months C. 9 months D. 12 months
D. 12 months Rationale: A child's birth weight usually triples by 12 months and doubles by 4 months. No specific birth weight parameters are established for 7 or 9 months.
At which of the following ages would the nurse expect to administer the varicella zoster vaccine to child? A. At birth B. 2 months C. 6 months D. 12 months
D. 12 months Rationale: The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years.
When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done? A. 1 month B. 2 months C. 3 months D. 4 months
D. 4 months Rationale: Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate.
Which of the following toys should the nurse recommend for a 5-month-old? A. A big red balloon B. A teddy bear with button eyes C. A push-pull wooden truck D. A colorful busy box
D. A colorful busy box Rationale: A busy box facilitates the fine motor development that occurs between 4 and 6 months. Balloons are contraindicated because small children may aspirate balloons. Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years. A 5-month-old is too young to use a push-pull toy.
A mother tells the nurse that her child does not want anything to do with toilet training and yells "No!" consistently when she tries to toilet train. The child is 2 years old. According to Erikson, the nurse interprets that the child is experiencing which psychosocial crisis? A. Initiative versus guilt B. Trust versus mistrust C. Industry versus inferiority D. Autonomy versus shame and doubt
D. Autonomy versus shame and doubt Rationale: The crisis of autonomy versus shame and doubt is related to the developmental task of gaining control of self and environment as exemplified by toilet training. Trust versus mistrust is the crisis of the infant. Initiative versus guilt is the crisis of the preschool and early school-age child. Initiative versus inferiority is the crisis of the 6- to 12-year-old child.
The clinic nurse is performing an assessment on a 12-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement if the 12-month-old infant is able to do which task? A. Produce cooing sounds. B. Obey simple commands. C. Produce babbling sounds. D. Begin to use simple words.
D. Begin to use simple words. Rationale: Simple words, such as mama, and the use of gestures to communicate begin when the infant is between 9 and 12 months old. A 1- to 3-month-old infant will produce cooing sounds. Babbling is common in a 3- to 4-month-old infant. Between the ages of 8 and 9 months, the infant begins to understand and obey simple commands, such as "wave bye-bye." The use of single-consonant babbling occurs between the ages of 6 and 8 months.
A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler's fontanels, what should the nurse expects to find? A. Open anterior and fontanel and closed posterior fontanel B. Open anterior and posterior fontanels C. Closed anterior fontanel and open posterior fontanel D. Closed anterior and posterior fontanels
D. Closed anterior and posterior fontanels Rationale: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.
The nurse is observing children playing in the hospital playroom. She would expect to see 4-year-old children playing: A. Competitive board games with older children B. With their own toys along side with other children C. Alone with hand held computer games D. Cooperatively with other preschoolers
D. Cooperatively with other preschoolers
While performing physical assessment of a 12 month-old, the nurse notes that the infant's anterior fontanel is still slightly open. Which of the following is the nurse's most appropriate action? A. Notify the physician immediately because there is a problem. B. Perform an intensive neurological examination. C. Perform an intensive developmental examination. D. Do nothing because this is a normal finding for the age.
D. Do nothing because this is a normal finding for the age. Rationale: The anterior fontanel typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanel as still being slightly open is a normal finding requiring no further action. Because it is normal finding for this age, notifying he physician or performing additional examinations are inappropriate.
Which of the following is the best method for performing a physical examination on a toddler A. From head to toe B. Distally to proximally C. From abdomen to toes, the to head D. From least to most intrusive
D. From least to most intrusive When examining a toddler or any small child, the best way to perform the exam is from least to most intrusive. Starting at the head or abdomen is intrusive and should be avoided. Proceeding from distal to proximal is inappropriate at any age.
Which of the following should not be fed to a toddler? A. Bananas B. Green beans C. Cake D. Grapes
D. Grapes Rationale: While cake is high in sugar and fat, grapes pose a choking hazard for toddlers and should be avoided for safety reasons. Bananas and green beans are appropriate for children of this age.
A 4-year-old child is reluctant to take deep breaths after abdominal surgery. Which measure is most appropriate to implement to encourage deep breathing? A. Give the child colorful latex balloons to blow up. B. Tell the child to exhale forcefully through the peak flow meter. C. Administer chest percussion in several postural drainage positions. D. Have the child pretend he is the big, bad wolf blowing the little pig's house down.
D. Have the child pretend he is the big, bad wolf blowing the little pig's house down. Rationale: The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene. Balloons are unsafe because of the potential aspiration of latex. The peak flow meter is used to assess vital capacity rather than to encourage breathing. Chest percussion and postural drainage will not affect depth of respiration.
The nurse performs an assessment on a 9-month-old infant. Which finding indicates a physiological problem and the need for follow-up? A. Absence of rooting reflex B. Inability to stand without support C. Creeping or crawling along the floor D. Head lag is noted when pulled to sitting
D. Head lag is noted when pulled to sitting Rationale: Presence of head lag after 6 months suggests neuromuscular dysfunction and indicates a physiological problem in an infant that is 9 months of age. Basic reflexes, such as rooting or startling, predominate the first 3 months and would not be reflexive in late infancy. Standing alone is not expected until 10 to 12 months, and crawling is accomplished by 6 to 8 months of age.
While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected? A. A strong Moro reflex B. A strong parachute reflex C. Rolling from front to back D. Lifting of head and chest when prone
D. Lifting of head and chest when prone Rationale: A 3-month-old infant should be able to lift the head and chest when prone. The Moro reflex typically diminishes or subsides by 3 months. The parachute reflex appears at 9 months. Rolling from front to back usually is accomplished at about 5 months.
Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is learning forward and drooling? A. Auscultate his lungs and place him in a mist tent. B. Have him lie down and rest after encouraging fluids. C. Examine his throat and perform a throat culture D. Notify the physician immediately and prepare for intubation
D. Notify the physician immediately and prepare for intubation Rationale: The child is exhibiting classic signs of acute epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening emergency. Having the child lie down would cause additional distress and may result in respiratory arrest. Throat examination may result in laryngospasm that could be fatal.
The adolescent's inability to develop a sense of who he is and what he can become results in a sense of which of the following? A. Shame B. Guilt C. Inferiority D. Role diffusion
D. Role diffusion Rationale: According to Erikson, role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame when they do not achieve autonomy. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. School-aged children develop a sense of inferiority when they do not develop a sense of industry.
The nurse is caring for a child with a ventricular septal defect, and the parents ask the nurse about the treatment for this disorder. On what should the nurse base the response? A. It is treated by medications alone. B. Surgical closure is done immediately. C. Surgical closure is done at ages 5 to 6. D. Some defects may close spontaneously.
D. Some defects may close spontaneously. Rationale: In ventricular septal defects, some defects may close spontaneously. If spontaneous closure does not occur, moderate or large defects require surgical closure before school age. If pulmonary hypertension is present, closure is necessary by age 1. Open heart surgery is done for closure.
The well-baby clinic nurse is assessing the motor developmental of a 30-month-old child. Which is the highest level of development that the nurse should expect to note in the child? A. The child opens a doorknob. B. The child unzips a large zipper. C. The child builds a tower of two blocks. D. The child puts on simple clothes independently.
D. The child puts on simple clothes independently. Rationale: At age 15 months, the nurse would expect that the child could build a tower of two blocks. A 24-month-old would be able to open a doorknob and unzip a large zipper. At age 30 months, the child would be able to put on simple clothes independently.
When administering an I.M. injection to an infant, the nurse in charge should use which site? A. Deltoid B. Dorsogluteal C. Ventrogluteal D. Vastus lateralis
D. Vastus lateralis Rationale: The recommended injection site for an infant is the vastus lateralis or rectus femoris muscles. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be used only in toddlers who have been walking for about 1 year.
The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is: a. "He is always hungry." b. "He tires out during feedings." c. "He is fussy for several hours every day." d. "He sleeps all the time."
b. "He tires out during feedings." Fatigue during feeding or activity is common to most infants with congenital cardiac problems.
